Resource-poor Environment Research Articles

Meningitis and brain abscess: First but fatal presentation in a child with tetralogy of fallot

Brain abscess is a known complication of cyanotic congenital heart diseases. We report the case of a four-year-old girl whose first presentation in the hospital was because of symptoms referable to the neurological system. These symptoms are similar to those seen in cerebral malaria as well as other infections of the central nervous system, e.g. meningitis and encephalitis. Detailed history, painstaking examination, and investigations will however help in differentiating these conditions. In the index case however, the illness was fatal due to the late presentation, which is not uncommon in this environment. In a resource-poor environment such as Nigeria, this is a reminder that proper history taking, clinical examination, and subsequent investigations will aid in early diagnosis and subsequent management of such cases to reduce childhood mortality. It also underscores the need for increased awareness among primary health care providers.<Learning objective: In developing countries where definitive treatments for most congenital heart diseases are not available, complications such as brain abscesses are not uncommon. Primary health care givers should be aware of these complications in these patients. Symptoms such as headaches, fever, and convulsions are common in children living in malaria endemic regions and may mimic the symptoms seen in brain abscess. A high index of suspicion is required to make prompt diagnosis and give appropriate treatment while treating children with congenital heart disease.>

Indications and outcome of thoracotomy in a new cardiothoracic unit in sub-Saharan Africa

Thoracotomy is a major thoracic surgery procedure that has various indications and can be marred with various complications and occasionally dismal outcome especially in resource poor environment like ours.

Comparison of sepsis definitions in a resource poor environment

Sepsis is an important cause of childhood death in developing countries. The International Pediatric Sepsis Consensus Conference (IPSCC) guidelines for definition has five categories and requires complex information, which may be difficult to access in resource poor settings, possibly leading to under-diagnosis and problems with triage, referral and documentation for public health assessments. We aimed to provide a workable system for grading sepsis categories, assess this against the IPSCC definition and use this information to guide further adaptations. We conducted a prospective observational study of consecutive admissions to a pediatric intensive care unit of a public hospital between August and September 2006. We recorded history and demographic, clinical, investigative, treatment and outcome details. We compared the performance of the IPSCC scoring system to the modified system. We studied one hundred consecutive admissions and collected data for the modified format. The distribution of sepsis cases and (deaths) was as follows: systemic inflammatory response syndrome 26 (2), sepsis 30 (5), severe sepsis/septic shock 15 (11), organ dysfunction 2 (2) and no sepsis 27 (3). Overall mortality was 23%. Despite its simplicity, the modified system corresponded well to the IPSCC system except for the systemic inflammatory response syndrome category. We suggest adaptations to improve agreement with IPSCC whilst maintaining ease of use. It is possible to simplify the IPSCC score to provide information in a resource poor setting but only further studies will be able to assess robustness in the field.

Severe leg trauma in a resource-poor environment: indications for amputation in emergencies

Although the development of multitissue limb reconstruction has reduced the role of post-traumatic primary amputation of the leg, some patients should nonetheless undergo emergency amputations. In developing countries, the socioeconomic context associated with the limited health care supply compromises still further the prognosis of preservation efforts. The decision criteria for surgery are thus different in these settings. The choice of emergency leg amputation or attempted preservation in developing countries depends on the epidemiology of severe leg trauma, the local and general prognosis, and the practice conditions. Three factors must be combined before limb preservationcan be attempted: adequate local and general adequate wound elements, an available, experienced surgeon with a competent care structure, and a favorable social context.

Lymphomas in Ile-Ife, Nigeria: Immunohistochemical Characterization and Detection of Epstein-Barr virus Encoded RNA.

The proper histopathological characterization of malignant lymphomas requires the use of immunohistochemistry along with other molecular pathology techniques. Malignant lymphomas histologically diagnosed in our hospital were reclassified according to the WHO scheme using immunohistochemistry while in-situ hybridization was performed for the detection of Epstein-Barr virus encoded RNA. There were 83 cases of lymphoma. The male to female ratio was 1.9:1 while the overall mean age was 41.7 years. Non-Hodgkin lymphomas (NHL) constituted about 79.5% of cases. The majority of cases (98.8%) were B-cell lymphomas. Nine subtypes of lymphomas were identified with diffuse large B-cell lymphomas (56.4% of which were of the germinal centre type) constituting the largest group (47.0%). Intermediate and high grade subtypes were more common. The majority of cases (72.3%) were nodal lymphomas with cervical lymph node being the commonest site (48.2%). Only classical Hodgkin lymphoma (HL) (20.5%) was seen of which the mixed cellularity subtype was the most common. Epstein Barr virus (EBV) encoded ribonucleic acid was detected in 7 cases (8.4%) including 4 cases of HL, 2 cases of Burkitt lymphoma and the only case of plasmablastic lymphoma. About five cases were reclassified as non-lymphoid malignant lesions. Immunohistochemistry is vital to the proper classification of lymphomas even in a resource poor environment. Although nine subtypes of lymphomas were identified, diffuse large B-cell lymphomas formed the largest single group. Epstein-Barr virus probably plays an important role in lymphomatogenesis in this environment. A larger multicentre study is required to prove this.

Opportunities to assess factors contributing to the development of the intestinal microbiota in infants living in developing countries.

Recent evidence suggests that establishment of a healthy gut microbiota shortly after birth is important to achieve optimal growth and development of children. Being born into a resource-poor environment presents challenges to the establishment of a healthy gut microbial flora in the newborn. Among these challenges are births that occur at home, traditional pre-lacteal feeding of newborns leading to failure to initiate lactation, poor sanitation and water quality, early environmental exposure to, and infection with, enteric or other pathogens, suboptimal breast feeding duration and intensity, deficiencies in weaning and childhood diets contributing to micro- and macro-nutrient deficiencies, and the frequent use of antibiotics. These factors should be considered in the design and implementation of preventive and therapeutic interventions aimed at improving the health and development of these children.

Peer training and co-learning in global health care.

The Zambia Anaesthesia Development Project (ZADP) is a an international health care partnership between the UK and Zambia, designed to mutually benefit anaesthetic registrars from both countries in aspects deficient in their native training schemes. The ZADP evolved from an initial plan to support a new anaesthesia training programme in Zambia, with visiting trainees providing continuity that was missing from short-term consultant visits. The primary goal of the project was to improve patient safety and care by delivering teaching, and by developing management, leadership and governance structures. An important reciprocal goal was to provide a unique training experience for a UK registrar in a resource-poor environment, including the resulting clinical and non-clinical challenges. This model adds a useful dimension to the educational support provided, and also embodies the principle of co-development The ZADP and the Zambia Master of Medicine (MMed) Anaesthesia programme provides an example of a cross-cultural peer-directed co-learning model that benefits trainees from developed and developing postgraduate training programmes. This synergistic model is one that could be applied to other educational initiatives supported from overseas. This model not only adds a useful dimension to the educational support provided, but also embodies the principle of co-development that is so important to the sustainability of such projects.

Teaching blind nasal intubation in Rwanda

To the Editor, The editorial by Dr. Wilkinson offers us an opportunity to further discuss our experience in Rwanda and counter his misimpressions. While recognizing Dr. Wilkinson’s vision and support of parturients’ health issues in Rwanda, we respectfully disagree with his view of the utility of teaching blind nasal intubation to Rwandan anesthesia trainees and staff. Our disagreement is based on a fundamental principle that ‘‘patients come first.’’ Our view of the utility of blind nasal intubation in a resourcepoor environment is based on this cornerstone of medicine. The basic principle of airway management is to provide adequate oxygenation and ventilation to patients. This principle is necessarily dependent on the tools available to health care providers in their particular environment. In the United Kingdom, for example, there is little need to teach blind nasal intubation, except perhaps in emergency settings. It is probably more useful to teach videolaryngoscopy as these devices are widely available in the developed world. In contrast, it would make little sense to teach videolaryngoscopy or even flexible bronchoscopic intubation in an austere environment with limited resources such as Rwanda, where such tools are not readily available. The value of blind nasal intubation is that it requires only an endotracheal tube. Of course, there are limitations in the use of trainingmannequins such as we described. These limitations, however, do not preclude the value of mannequins for teaching basic airway techniques, particularly as the alternative is a human subject. Teaching airway management using mannequins improves performance as simulation allows a safe environment for acquiring skills through practice without compromising patient safety. This is a settled question. We believe that Dr. Wilkinson is simply incorrect in his assertion that teaching blind nasal intubation using mannequins is ‘‘antiquated’’ and ‘‘obsolete.’’ Dr. Wilkinson stated that if one of his family members were pregnant and required an anesthetic for delivery in Rwanda, he would not be comfortable knowing that the caregivers had learned to perform blind nasal intubation on a mannequin in a classroom. This surely is overstated, considering that there are only 12 anesthesiologists in Rwanda serving a population of 11 million people. Anesthesia technicians with limited training in airway management provide most of the anesthesia care in Rwanda. It is likely that his family member would receive an anesthetic provided by an anesthesia technician. Would it not be more reasonable – and safer – to receive the anesthesia from a Rwandan anesthesia technician who has undergone a continuing program of training in airway management that included practice on a mannequin with blind nasal intubation? One can hardly disagree that it is safer to have a technician trained in airway management than to have one who is untrained. Airway skills are the foundation of all anesthesia management. International organizations, including the World Federation of Societies of Anaesthesiologists, should support Global Outreach Program initiatives to properly train anesthesia personnel in basic airway management skills. Editor’s Note: The author of the article: Can J Anesth 2014; 61: 975-8, respectfully declined an invitation to submit a reply to the above Letter to the Editor.

Can you learn to lawyer online? A blended learning environment case study

Law students’ future clients and employers, and the broader community, all deserve graduates to be equipped with not only substantive legal knowledge, but also a range of skills and practical knowledge. However, most law schools face resource pressures that mean that traditional skills development methodologies (which are often resource intensive) can only be used judiciously. In this resource-poor environment, skills development methodologies which incorporate new technologies can be one way to assist law students to develop the professional skills they require. Online learning tools have the potential to be resource friendly, and law schools may therefore be able to utilise them to ensure that maximum learning potential is achieved from the limited resources available. Considering an online or blended skills development framework is also supported by evidence that new technology learning tools can usefully contribute to skills development. In this article the potential for online learning to replicate aspects of an apprenticeship model of learning is explored, as a means of explaining this contribution. This analysis is intended to facilitate consideration of a broad panoply of learning tools for skills development, and inform educators considering adding a new technology component to student skills development.

Global Health: Role of HPV Testing in Resource Poor Environment

Global Health: Role of HPV Testing in Resource Poor Environment Eighty-five percent of cervical cancer deaths occur in the developing world. While cervical cancer is only the tenth most common cancer in women in developed countries, it is the leading cause of cancer related deaths in women in low and middleincome countries (LMICs). Despite this, there is a disproportionate allocation of cervical-cancer related resources in countries with the highest burden. Cervical cancer is preventable and amenable to early detection and treatment. Over the past two decades, largescale data investigating low cost screening interventions have demonstrated efficacy of cervical cancer prevention in many continents.

Feeding the Larger Low-Birthweight Infant in a Resource-Poor Environment.

The high low birthweight prevalence in resource-poor countries (16.5%) places a burden on overstretched resources. Labor ward must have written guidelines to triage these infants for optimal nutritional support to the special care nursery (SCN; 1,500-1,800 g and <34 weeks) and postnatal ward (PW; >1,800 g and ≥ 34 weeks). Separation of mother and infant should be prevented. Initiating breastfeeding and kangaroo mother care (KMC) in labor ward by skilled nurses in the latter group is a priority and continues in the PW. SCN infants receive an intravenous 10% glucose-electrolyte solution and, if stable, commence with expressed colostrum and breast milk (EBM) feeding and intermittent KMC which progresses to continuous KMC and breastfeeding. Enteral feeding is advanced more slowly in unstable infants. Parenteral nutrition is only administered to infants with bowel obstruction or feeding intolerance. EBM of HIV+ mothers in the SCN is pasteurized. The decision to discharge a mother-infant dyad should be individualized. Infants in the SCN are discharged at 34 weeks, a weight of 1,600-1,800 g and are gaining adequate weight. Discharge from the PW usually takes place after 48 h, often before the infant has regained his birthweight but breastfeeding must be established. Multivitamin- and iron-containing syrup is continued for at least 12 months. The clinics in the community must provide postdischarge nutritional support.

Low-Cost Low-Maintenance Paper-Based Sensor for the Detection of Ebola Virus

Recent outbreak of Ebola virus that causes hemorrhagic fever shows that the quick detection of this virus in a resource-poor environment is extremely important for controlling the epidemic. Existing methods based on enzyme-linked immunosorbent assay (ELISA), polymerase chain reaction (PCR) or isolation of the virus require expensive equipment, skilled personnel and the highest biosafety level. We highlight here a recent demonstration of low-cost low-maintenance synthetic biology for detection of Ebola virus based on paper as a device substrate.

Use of a Foley catheter balloon as a tool during endoscopic frontal sinus surgery in a resource-poor environment.

This study aimed to evaluate the non-Food and Drug Administration-approved off-label use of a 10F Foley catheter as a tool during endoscopic frontal sinus surgery. A cohort of 40 patients with chronic frontal rhinosinusitis was prospectively evaluated using the Sino-Nasal Outcome Test (SNOT-22), computed tomography (CT) imaging, and endoscopic examination. Endoscopic sinus surgery (ESS) was performed in the usual fashion, however, when approaching the frontal sinus, a 10F Foley catheter was inserted and the balloon inflated in the frontal outflow. Patients were assessed postoperatively with SNOT-22, CT imaging, and endoscopic assessment at 6 months. Successful intraoperative dilation of the frontal recess was achieved in 62 of 69 frontal sinuses (90%). No cerebrospinal fluid leak or orbital entry occurred. Six months postoperative, SNOT-22 scores showed significant improvement, whereas endoscopic assessment revealed patent frontal recess in 55 of 62 (89%) frontal sinuses. Computed tomography imaging was completed in 25 patients comprising 41 operated frontal sinuses with no mucosal thickening seen in 37 of 41 (90%). The 10F Foley catheter is an effective tool to dilate the frontal recess by compression of edema during ESS. It may be a safe and cost-effective alternative to high-cost commercially available sinus balloons, especially in resource-poor environments.

Population dynamics and spatial ecology of a declining desert rodent,Pseudomys australis: the importance of refuges for persistence

Desert rodents exhibit irruptive (boom–bust) population dynamics in response to pulses of primary productivity. Such unpredictable population dynamics are a challenge for monitoring population trends and managing populations, particularly for species in decline. We studied the population dynamics and occurrence of populations of the vulnerable plains mouse, Pseudomys australis (42-g body mass), during the low (bust) phase of the cycle in the Simpson Desert, Australia, to examine the use of refuges by the species and the predation pressure experienced from native and introduced predators. Specifically we investigated landscape-scale occurrence; body mass, reproduction, and population size; and presence of native and introduced predators. Our results demonstrate that P. australis contracted to discrete areas of the landscape (refuges) during the low phase and that these areas occupied a small proportion (~17%) of the range occupied during population peaks. Animals in refuge populations had comparable body mass, occurred at similar densities to populations during the boom phase, and continued to reproduce during dry conditions. Such refuges represented a significant concentration of biomass to predators in a resource-poor environment. Native predators were rare during the low phase, suggesting that refuges naturally experienced low predation levels. Two introduced predators, feral house cats and red foxes, persisted during the low phase and exploited refuge populations of P. australis, thus representing a significant threat to population persistence. We advocate a novel approach to management of rodents in arid systems that involves identifying the discrete parts of the landscape that function as drought refuges and then focusing threat management there. The relatively small size of these refuges increases the likelihood of cost-effective management.

Caregiving and the experience of health and illness in children living with HIV/AIDS in Gulu District Northern Uganda: An ethnographic research narrative

In this paper we discuss the experience of caregiving for children living with HIV in a resource poor environment in Gulu municipality in northern Uganda; the main research questions of the study were: what are the perceptions of caregivers on the care of children with HIV, and what barriers and enablers exist that undermine or promote better care for children respectively? The experience of caregivers and their perceptions on managing HIV in children is believed to shape the health seeking behaviour towards treatment and efforts to cope with its negative impact on the body. Women and children are the greatest bearer of the burden of the HIV scourge to date. While more and more children are undergoing treatment as a way of controlling HIV/AIDS, it is still crucial to understand the perceptions of their parents and/or caregivers on the AIDS pandemic and the impact of antiretroviral therapy on the quality of life of their children. In this paper the socio-medical views of these clients, based on an ethnographic study are discussed to give a holistic understanding of the ‘crisis’ of HIV/AIDS as well as their ‘imagined’ hopes, fears and expectations on antiretroviral therapy as HIV/AIDS become a chronic disease. Five themes emerged from analysing the experiences and perceptions of caregivers of children living with HIV: beliefs in the antiretroviral therapy, psychological counselling, family breakdown, positive living with HIV and social stigma. These were central in their perception of caring for the affected children and other family members.

A Feasibility Study of Mobile Phone Text Messaging to Support Education and Management of Type 2 Diabetes in Iraq

We undertook a feasibility study to evaluate feasibility and utility of short message services (SMSs) to support Iraqi adults with newly diagnosed type 2 diabetes. Fifty patients from a teaching hospital clinic in Basrah in the first year after diagnosis were recruited to receive weekly SMSs relating to diabetes self-management over 29 weeks. Numbers of messages received, acceptability, cost, effect on glycated hemoglobin (HbA1c), and diabetes knowledge were documented. Forty-two patients completed the study, receiving an average 22 of 28 messages. Mean knowledge score rose from 8.6 (SD 1.5) at baseline to 9.9 (SD 1.4) 6 months after receipt of SMSs (P=0.002). Baseline and 6-month knowledge scores correlated (r=0.297, P=0.049). Mean baseline HbA1c was 79 mmol/mol (SD 14 mmol/mol) (9.3% [SD 1.3%]) and decreased to 70 mmol/mol (SD 13 mmol/mol) (8.6% [SD 1.2%]) (P=0.001) 6 months after the SMS intervention. Baseline and 6-month values were correlated (r=0.898, P=0.001). Age, gender, and educational level showed no association with changes in HbA1c or knowledge score. Changes in knowledge score were correlated with postintervention HbA1c (r=-0.341, P=0.027). All patients were satisfied with text messages and wished the service to be continued after the study. The cost of SMSs was €0.065 per message. This study demonstrates SMSs are acceptable, cost-effective, and feasible in supporting diabetes care in the challenging, resource-poor environment of modern-day Iraq. This study is the first in Iraq to demonstrate similar benefits of this technology on diabetes education and management to those seen from its use in better-resourced parts of the world. A randomized controlled trial is needed to assess precise benefits on self-care and knowledge.

Predictors of Abdominal Obesity among Adult Nigerians in a Resource-poor Environment of a Rural Hospital in Eastern Nigeria

Background: Abdominal obesity once considered an aesthetic rather than a pathological condition is now recognized as a principal risk factor for metabolic syndrome and magnifies the risk of cardiovascular diseases. As the case detection rate of abdominal obesity increases in Nigeria determining its predictors remain relevant for proactive control intervention.

Adherence to Lifestyle Modifications among Adult Hypertensive Nigerians with Essential Hypertension in a Primary Care Clinic of a Tertiary Hospital in Resource-poor Environment of Eastern Nigeria

Background: Lifestyle modifications (LSMs) are indispensable in blood pressure control among hypertensive patients. However, the extent to which patients lifestyles (LS) coincide with clinical prescriptions has become an important management challenge in primary care.

Temporomandibular joint dislocation: experiences from Zaria, Nigeria.

ObjectivesDislocation of the temporomandibular joint may occur for various reasons. Although different invasive methods have been advocated for its treatment, this study highlights the value of non-invasive treatment options even in chronic cases in a resource-poor environment.Materials and MethodsA seven-year retrospective analysis of all patients managed for temporomandibular joint dislocation in our department was undertaken. Patient demographics, risk factors associated with temporomandibular joint dislocation and treatment modalities were retrieved from patient records.ResultsIn all, 26 patients were managed over a seven-year period. Males accounted for 62% of the patients, and yawning was the most frequent etiological factor. Conservative treatment methods were used successfully in 86.4% of the patients managed. Two (66.7%) of the three patients who needed surgical treatment developed complications, while only one (5.3%) patient who was managed conservatively developed complications.ConclusionTemporomandibular joint dislocation appears to be associated with male sex, middle age, yawning, and low socio-economic status, although these observed relationships were not statistically significant. Non-invasive methods remain an effective treatment option in this environment in view of the low socio-economic status of the patients affected.

Root architecture and ecological adaptation strategies in three shelterbelt plant species in the southern Taklimakan Desert

Aims Root architectural properties influence the efficiency and cost of resource exploitation of plants. This paper aims to investigate the root topological properties and ecological adaptation strategies of three plant species which play important roles in wind shelterbelt in the southern Taklimakan Desert of China. Methods We excavated the coarse root systems of three shelterbelt plant species (Tamarix ramosissima, Haloxylon ammodendron, Populus alba var. pyramidalis) at a study site in the southern Taklimakan Desert and analyzed their root architectural properties, including topology, root length, diameter, and scaling relations. Important findings We found differences as well as similarities in the topological structure of root systems among the three plant species. The differences in root structure reflected different adaptation strategies among the plants to soil environment. The root branching order in both T. ramosissima (qa = 0.46, qb = 0.13, TI = 0.84, qa and qb show normed values corresponding to parameters a and b, respectively, TI shows topological index) and H. ammodendron (qa = 0.63, qb = 0.19, TI = 0.90) resembled the herringbone structure; whilst it was dichotomous in P. alba var. pyramidalis (qa = 0.03, qb = 0.02, TI = 0.49). The main root length in the three plant species was all very along. Longer root length could reduce the internal competition of roots for nutrients, so that plants were better cope with the resource-poor sandy soil environment. The Leonardo da Vinci theory is supported in this study with the three plant species.